Does a proximal colostomy affect colorectal anastomotic healing?

Compression anastomoses in colon and rectal surgery with the NiTi ColonRing™

BACKGROUND

The aim of this prospective study was to evaluate safety and efficacy of the NiTi ColonRing™ for anastomoses on the colon or rectum.

METHODS

During the period September 2008-June 2011, anastomosis using the NiTi ColonRing™ was scheduled to be performed on 60 patients (36 females, 24 males/mean aged 67 years), 53 of whom underwent colectomy for cancer and 7 reconstruction after Hartmann's procedure. Application of the device failed in one case due to anatomical reasons. Colorectal resections performed were as follows: Right hemicolectomy (5 patients), left colectomy (2), sigmoidectomy (15) and low anterior resection (31). A follow-up clinic visit after 1 month was planned for all patients. Ten patients among the first 14 had rectosigmoidoscopy at 2-3 months. All cancer patients were scheduled for colonoscopy at 12 months.

RESULTS

No intraoperative or postoperative bleeding related to the anastomotic technique was recorded. Median hospital stay after surgery was 10.2 days (9-22 days). One patient died on day 13 due to myocardial infarction. Clinically apparent leak was detected in one patient who had undergone reconstruction after Hartmann; the only treatment required was total parenteral nutrition for 12 days. Anastomotic stenosis occurred in another one patient who had undergone reconstruction after Hartmann; it was easily resolved by balloon dilatation. Mild complications were encountered in 23 other patients (39%). Oral feeding started after day 4. Anastomotic rings were expelled naturally within 7-17 days (mean, 9.2 days). A satisfactory anastomosis was revealed in patients examined colonoscopically at 2-3 and 12 months. Mean follow-up was 15.2 months (2-33 months).

CONCLUSIONS

NiTi ColonRing™ is reliable, safe and efficacious for large bowel anastomoses.

Estudo do efeito da colostomia proximal terminal na cicatrização de anastomoses colo-cólicas em ratos

OBJETIVO: Estudar os efeitos da colostomia proximal terminal na cicatrização de anastomoses colo-cólicas em ratos. MÉTODOS: 36 ratas foram divididas em 2 grupos: grupo controle (C) com 12 animais submetidos à ressecção cólica segmentar seguida de anastomose colo-cólica primária, e grupo colostomizado (CZ) com 24 animais submetidos ao mesmo procedimento do grupo C complementado com uma colostomia proximal. A cicatrização anastomótica foi avaliada em dois períodos distintos, 2º e 7º dias de pós-operatório (PO), em relação à deiscência anastomótica, aderências, epitelização mucosa, pressão de ruptura e variáveis histológicas. Os resultados foram submetidos a estudo estatístico considerando-se como significante valores de p<0,05. RESULTADOS: A deiscência, principal variável analisada nessa pesquisa, não ocorreu em ambos os grupos estudados. As aderências foram significantemente mais intensas no grupo C no 7º PO. Nos dois grupos, a ruptura intestinal sempre ocorreu ao nível da anastomose no 2º PO; no 7º PO, a maior parte das rupturas aconteceram na alça cólica fora da zona anastomótica (100% do grupo C e 70% do grupo CZ). A análise das demais variáveis demonstrou equivalência entre os dois grupos. CONCLUSÃO: Os resultados dessa pesquisa não demonstraram diferença significante entre anastomoses colo-cólicas em ratos associados ou não à colostomia proximal.

Avaliação do efeito da colostomia proximal na cicatrização de anastomoses colocólicas em ratos com obstrução intestinal

OBJETIVO: Avaliar o efeito da colostomia proximal na cicatrização de anastomoses colocólicas em ratos com obstrução intestinal. MÉTODO: 72 ratos foram divididos em três grupos: grupo controle (C), submetido à anastomose colocólica e à colostomia proximal na ausência de oclusão intestinal; grupo sem colostomia (SC), submetido à oclusão intestinal de 72 horas e à anastomose colocólica primária; grupo com colostomia (CC) submetido à oclusão intestinal de 72 horas, à anastomose colocólica primária e à colostomia proximal. A cicatrização anastomótica foi avaliada em dois períodos, nos 2º e 7º dias de pós-operatório, em relação à deiscência anastomótica, aderências, epitelização mucosa, pressão de ruptura e a variáveis histológicas por estudo convencional e informatizado. RESULTADOS: verificou-se maior tendência a deiscência anastomótica no grupo SC (12,5%), e elevada incidência de complicações da colostomia no grupo CC (13%), entretanto tais resultados não apresentaram diferença estatística significante. No que se refere às demais variáveis analisadas para verificação da cicatrização anastomótica deve-se considerar que houve equivalência entre os três grupos nos dois períodos analisados. CONCLUSÃO: Não há diferença entre a cicatrização de anastomoses colocólicas associadas ou não à colostomia proximal, em ratos com obstrução intestinal.

Compression anastomosis (AKA-2) in colorectal surgery: results in 442 consecutive patients

BACKGROUND

The morbidity and mortality associated with colorectal surgery results partly from anastomotic leakage. Animal experiments have shown some advantages of sutureless anastomosis over conventional colorectal anastomosis. Compression anastomosis follows the same biological principles as sutureless anastomosis.

METHODS

The compression anastomosis AKA-2 was evaluated in a prospective consecutive audit of 442 patients between September 1989 and August 1998.

RESULTS

Anastomoses were performed in 372 elective and 70 emergency situations. The indication for operation was colorectal cancer (56.3 per cent) and diverticulitis (23.5 per cent). A defunctioning colostomy was performed in 110 patients (24.9 per cent). Fourteen patients died (3.2 per cent). Death was related to anastomotic complications in three patients (0.7 per cent). Twenty-four patients (5.4 per cent) developed intra-abdominal complications. There were 11 symptomatic (2.5 per cent) and six asymptomatic (1.4 per cent) leakages. Anastomoses that were more than 10 cm from the anal verge leaked in seven (2.4 per cent) of 291 cases, while anastomoses between 5 and 10 cm leaked in three (2.6 per cent) of 116 cases and those less than 5 cm from the anal verge leaked in one (3 per cent) of 35 cases.

CONCLUSION

The low incidence of anastomotic complications demonstrates good biological healing of compression anastomoses. The compression anastomosis AKA-2 is safe in both high and low anterior resection and can therefore be recommended for use in colorectal surgery.

Blood flow in colon anastomotic stricture formation

PURPOSE

The influence of both blood flow and anastomotic technique on the development of anastomotic stricture formation was studied using a dog model.

METHODS

Fifty-three dogs underwent distal colocolonic anastomosis with either an EEA (U.S. Surgical Corp., Norwalk, CT) circular stapler or a Czerny-Lembert two-layered, handsewn anastomosis. Blood flow was measured by Laser Doppler Velocimetry using the Laserflo BPM2 (Vasamedics Inc., St. Paul, MN). The animals were separated into three blood flow groups: greater than or equal to 62.5 percent of normal blood flow, between 37.5 percent and 62.5 percent of normal blood flow, and less than or equal to 37.5 percent of normal blood flow. Each blood flow group had an anastomosis performed by either stapling or by hand sewing techniques. At six weeks, the anastomoses were opened longitudinally and fixed to determine the anastomotic index (AI). AI is defined as two times the anastomotic circumference over the proximal circumference plus the distal circumference. Blood flow groups and anastomotic technique groups were compared with an interaction variable for the outcome, AI using a two-way analysis of variance.

RESULTS

The AI of the stapled anastomoses was found to be significantly higher than handsewn anastomoses (P < 0.006). There was no difference in AI between different blood flow groups and no correlation of observed histologic findings with AI.

CONCLUSION

Clinically relevant ischemia does not directly influence stricture formation in either handsewn or stapled distal colonic anastomoses.

Influence of proximal end diverting colostomy on the healing of left-sided colonic anastomosis: an experimental study in rats

The purpose of this study was to evaluate the healing of an experimental left-sided colonic anastomosis in rats protected by an end diverting proimal colostomy. The anastomoses were studied by radiological and biochemical examination and breaking strength was estimated. The results were compared with a non-operated group and with a group of rats having a non-defunctional anastomosis constructed in the same manner. In animals with an end diverting colostomy, anastomotic protein levels and enzymic activity were lower than in those with a colostomy, and the development of anastomotic strength was delayed compared with those not defunctioned.